fort monroe

LAST NAME, FIRST NAME: SSN:

TOUR START DATE: # OF DAYS: (no more than 90 days).

JUSTIFICATION IF TOUR IS TO START OR END ON A WEEKEND OR HOLIDAY:

DOES INDIVIDUAL MEET HEIGHT/WEIGHT REG: YES NO (include DA5500 or DA5501)

CINC/MACOM's UIC FOR ATTACHMENT, FOR UCMJ:

IS RENTAL CAR AUTHORIZED: YES (if other than $35, show daily rate: ) _X NO

WHAT, IF ANY, SECURITY CLEARANCE LEVEL IS REQUIRED:

WILL CINC/MACOM FUND TRAVEL & PER DIEM: YES _X NO

IF CINC/MACOM IS PAYING TRAVEL & PER DIEM, IS DD1610 ENCLOSED: YES _X NO

MODE OF TRAVEL: AIR POV* _X LOCAL*

* IS IN & AROUND MILEAGE AUTHORIZED: YES (daily miles ) _X NO

IF INDIVIDUAL IS NOT LOCAL, ARE QUARTERS AVAILABLE: YES X_ NO

IF YES, LIST DAILY RATE: $_N/A

IF INDIVIDUAL IS NOT LOCAL, IS MESSING AVAILABLE: YES _X NO

WHAT, IF ANY, ADDITIONAL AUTHORIZATOINS ARE REQUIRED:

_N/A Foreign Language Proficiency Pay (show FLPP order number and/or attach DA330)

_N/A Hazardous Duty Pay - List Responsible Jump Agent:

N/A Aviation Career Inventive Pay (attach order)

IS THIS A PERSTEMPO TOUR: YES _X NO (state reason, i.e., w/i 100 miles, school, tour at IMA

agency, etc) This is ROTC Goldbar Recruiter Duty to be conducted local to the LT's host detachment and does

not incur per diem or travel expense

CINC/MACOM POC SHOULD REVIEW THE FOLLOWING BEFORE SENDING TO AR-PERSCOM:

DOES DA1058 INCLUDE STREET OR BLDG INFO AND ZIP CODE FOR REPORTING ADDRESS?

VERIFY HIV TEST RESULT DATE (w/i 6 MONTHS FOR TOURS OF 30 DAYS OR MORE/w/i 5 YEARS FOR

TOURS LESS THAN 30 DAYS)

IS ETS/MRD CURRENT?

IS ACTIVE FEDERAL SERVICE UNDER 17 YEARS?

DID INDIVIDUAL SIGN FRONT AND BACK PAGE OF DA1058?

FOR TPU MEMBERS, DID COMMANDER SIGN DA1058? N/A
IS DA7349 ENCLOSED?

CINC/MACOM REVIEW BY: PHONE: